RCGP ’ s 6th Health & Justice Summit: Safety through Continuity Friday 1 st February 2019

1. Inside Gender IdentityMeeting the health and social care needs of transgender people in the criminal justice system RCGP’s 6th Health & Justice Summit: Safety through Continuity Friday 1st February 2019 Dr Jon Bashford and Karen Lawson Community Innovations Enterprise jon@ciellp.comI karen@ciellp.com

2. Inside Gender Identity (December, 2017) Aim • To provide NHS England with an appropriate assessment of the evidence base on meeting the health and social needs of trans people in the criminal justice system. Methods • Literature review– separate report examining 200 research papers, articles and reports • Stakeholder engagement - involving 55 individuals including transgender prisoners

3. Trans and Criminal Justice Victims of crime, prejudice and discrimination • 73% of trans people surveyed experienced some form of harassment in public (ranging from comments and verbal abuse to physical violence); • 21% stated that they avoided going out because of fear of harassment; • 46% stated that they had experienced harassment in their neighbourhoods; • 1 in 4 trans young people experienced physical abuse at school; 64% of young trans men and 44% of young trans women experienced harassment or bullying at school, NB: not just from their fellow pupils but also from school staff including teachers; and • 28% stated that they had moved to a different neighbourhood because of their transition. (Whittle, et al. 2007) • 48% of respondents had been victims of assault, including sexual assault and rape, and 78% had experienced verbal harassment (Genderpac, 1997).

4. Trans and Criminal Justice Numbers of prisoners in England and Wales identifying as trans 2018 • 44 of the 124 public and private prisons (35%) in England and Wales said that they had 1 or more transgender prisoner • there were 139 prisoners currently living in, or presenting in, a gender different to their sex assigned at birth and who have had a local transgender case board; • of these, 111 reported their legal gender as male, 23 reported their gender as female and 5 did not state their gender; NB: When asked about the gender with which the prisoner identified themselves: • 114 identified as female; • 19 as male; and • 6 did not provide a response.

5. Trans and Criminal Justice • In terms of how they self-identified: • 27 identified as gender-fluid; • 10 as intersex; • 4 as non-binary; and • the remaining 48 gave preferred not to say. • There were 42 transgender prisoners in woman’s prisons. When asked about the gender with which the prisoner identified themselves, 22 identified as female 17 as male. and 3 did not provide a response. • There were 97 transgender prisoners in men’s prisons. When asked about the gender with which the prisoner identified themselves, 92 identified as female, 2 as male and 3 did not provide a response. Based on this exercise, there were 1.6 transgender prisoners reported per 1,000 prisoners in custody. (MOJ, 2018)

6. Trans and Criminal Justice

7. Trans and Criminal Justice Case numbers presenting at Liaison and Diversion Services - The number of cases identified by individual services remains low; therefore data should be treated with caution: • In 2016/17 there were 311 cases (0.5%), of service users who identified themselves as transgender. In the previous year it was 303 cases (0.7% of cases). • The proportion of service users identifying as transgender within a service varies from 1.5% of those seen in Cambridgeshire to less than 0.2% in many areas. • Other services recording a higher than average proportion of transgender service users are Sheffield (1.4%), Surrey (1.2%) and Leicestershire (1.1%).

8. Trans and Criminal Justice Patterns of offending behaviour “Trans people are stereotyped as a risk for sexual offending, as if they are just seeking access to women, we are in the business of risk assessment but it can be used as a smoke screen.” (Professional respondent, Criminal justice sector) Preventing Reoffending “The offender management programmes are accredited for males, there is no account for working with trans prisoners.” (Professional respondent, Criminal justice sector)

9. Trans health • “Every area of health is affected, it looks like things are happening but they are not, the focus is often on the physical sexual attributes and not the wider health needs.” (Professional respondent, Social sector) • “We are conditioned to deal with men’s health or women’s’ health, it is challenging when it is trans health.” (Professional respondent, Health sector practitioner) • “The focus is much more on where to place people in the prison estate than on their health needs.” (Professional respondent, Health sector commissioner)

10. Common issues that impact on healthcare • Coming out as trans in the criminal justice system “It’s not uncommon for people to come out as transgender for the first time in prison – this may not be picked up on the initial health screen.” (Professional respondent, Health sector practitioner) • Gender fluidity “Gender identity can be very fluid, people change what they say is their identification. This matters more in a prison environment.” (Professional respondent, Health sector practitioner) • Support for transition “…[staff] don't really understand the significance for mental health and the emotional impact of transition…not equipped to deal with the issues, the mood swings, the social impact like rejection from family and friends, hormone imbalances…”(Professional respondent, Criminal justice sector)

11. Common issues that impact on healthcare • Understanding about healthcare needs “There are many physical health needs, people still need health screening - breast screening, cervical screening, prostate etc.”(Professional respondent, Health sector practitioner) • Prescribing “If people are self medicating in the community, there are no routes to continue this in prison.”(Professional respondent, Health sector practitioner) • Social risks and needs –Isolation, The impact of coming out, Disability, Caring responsibilities, Unemployment • The health impacts of discrimination and prejudice

12. Common issues that impact on healthcare • Complex needs “Mental health is not equipped to deal with the issues – mental health, trans and forensic – in any depth, there are very few practitioners who could deal with this.”(Professional respondent, Health sector commissioner) “…staff say they can’t deal with trans issues at same time as personality disorder.”(Professional respondent, Health sector practitioner) • Drug use - 24% of trans people have used drugs within the last 12 months, the most common being cannabis, poppers and ecstasy (McNeil, et al. 2012). • HIV/AIDS “Many trans women have problems with health services, especially sexual health services, they avoid them because of fears about how they will be treated or past negative experiences, it can have a big impact on their care.” (Professional respondent, Health sector practitioner)

13. Trans health & Justice “We are trans blind – don't know level of need and don't share what experience we do have.” (Professional respondent, Health sector commissioner) “Trans gender is not routinely asked about anywhere in healthcare...” (Professional respondent, Health sector practitioner)

14. Improving safety and effectiveness • Safe from harm - At the point of arrest, Pre-sentence planning and the courts, Placement in the prison estate • Managing Risk and vulnerability - Stigma and discrimination; Bullying, harassment and violence; supporting trans prisoners to live in the gender role they identify with; clustering in the prison system • Young trans offenders • Preventing self-harm and suicide - Assessment, Care in Custody and Team work (ACCTs)

15. Improving safety and effectiveness 2. Health and social care pathways • Hormone therapy and related prescribing • An integrated care pathway • Gender Identify Clinics and offender health care pathways –Access, Experience, Outcomes

16. What is the current pathway of care for the individual? Primary healthcare Referral GIC Transgender case review ……… • Outcome(s)? • Seen by GIC and placed on pathway • Told to wait until end of sentence • Rejected because in prison • Rejected because mental health/substance/behavioural problems Mental health Physical health Hormones? Personality Disorder Drugs & Alcohol

17. Improving safety and effectiveness • GIC Access – barriers and exclusions “They [the GIC] said come back when I am released.”(Trans female prisoner) “The distance of a prison from a GIC will affect the likelihood of receiving a service.”(Professional respondent, Criminal justice sector) “The GICs won’t accept people living in role while they are in prison.” (Professional respondent, Social sector) “People are being punished twice – if they miss a GIC appointment then they are put back to the bottom of the queue, regardless of the reason. This is particularly difficult for people in prison where they have no control over their attendance.” (Professional respondent, Social sector) “The GICs refuse to treat people if they have mental health problems, substance problems – they expect people to sort these out first, but that can be difficult if it is all tied up with their gender dysphoria.”(Professional respondent, Health sector practitioner)

18. Improving safety and effectiveness 3. Skills and knowledge • Capacity • Culture, management practice and leadership • Addressing discriminatory practice • Recognising and sharing good practice

19. Learning from lived experience

20. Recommendations Competency and skills • Recommendation 1: Equality and Diversity Training • Recommendation 2: Practice guidance • Recommendation 3: Expert Champions Care and justice pathways • Recommendation 4: Appropriate and integrated care pathways • Recommendation 5: Offender management treatment programmes Gender identity clinics and offender pathways • Recommendation 6: Gender Identify Clinics Involvement and engagement with the trans social sector • Recommendation 7: Trans social sector involvement in support • Recommendation 8: A national trans health and justice network

21. Recommendations NHS England Inside gender Identity Delivery Group • Membership– NHS England, Public health England, HMPPS, Prison Governors, Government Equality Office, Transgender Voluntary Sector • Aim: to review the recommendations within the Inside Gender Identity Report including reviewing the recommendations and to propose groups, Departments or individuals to take these actions forward and monitor the implementation of these recommendations across the secure estate.

22. Report available at www.ciellp.net/inside-gender-identity